Increased Anxiety and Depression Symptoms in Post-Acute Care Patients with Stroke during the COVID-19 Pandemic

This study aimed to explore the quality and stability of post-acute care for patients with stroke, including their functional outcomes, mental health and medical care in Taiwan during the COVID-19 pandemic. In this retrospective case–control study—based on propensity score matching—we assessed 11 patients admitted during the pandemic period (in 2021) and 11 patients admitted during the non-pandemic period (in 2020). Functional outcomes, including the scores of the modified Rankin Scale, Barthel Index, EuroQoL-5 Dimension, Lawton–Brody instrumental activities of daily living, Berg Balance Scale, 5-metre walking speed and 6-min walking distance, were determined. Data on the length of acute care, length of post-acute care, destination after discharge and 14-days readmission were used to evaluate the quality of medical care. The Wilcoxon signed-rank test was used to compare functional performance before and after rehabilitation. The pandemic group showed no significant improvement in the scores of EuroQoL-5 Dimension, a self-reported health status assessment (p = 0.13), with the anxiety or depression dimension showing a negative effect (r = 0.21). Post-acute care programmes can efficiently improve the functional performance of patients with stroke during the COVID-19 pandemic in Taiwan. Mental health should therefore be simultaneously maintained while rehabilitating physical function.

I’m the Only Son She Got Left: Male Caregivers’ Experiences Managing Older Adults’ Post-Acute Care

Family caregivers (FCGs) play an integral role supporting older adults transitioning to post-acute care following a hospitalization. FCGs function as advocates, information agents, and most importantly, care managers and providers. Although, caregiving has been traditionally seen as a female role, men are increasingly undertaking these roles and responsibilities. This research addresses a gap in the existing literature by exploring the subjective experiences of male FCGs of older adults in the post-acute setting. Using data from two parent qualitative studies on caregiving in the post-acute setting (N=40), we conducted a qualitative secondary analysis using conventional content analysis of male caregiver participants’ interview data (n=11). Interviews explored the subjective experiences of male caregivers’ interactions with home health care supportive personnel and conducting medical/nursing tasks for older adults. Five themes emerged: areas of abandonment, financial needs, masculinity, organization of care, and preparation. These themes highlighted areas of both confidence and struggle for male FCGs and captured their unique experiences managing the care of an older adult in the post-acute setting. Furthermore, the themes illustrate male FCGs’ feelings of guilt, financial impact, work disruptions, and the perceived effect of masculinity on their caregiving role. Findings can inform clinicians’ provision of focused and tailored resources to meet the specific needs of male FCGs. Future research should explore the evolving experiences of male FCGs over time, particularly those FCGs of older adults with chronic illnesses.

Nursing Home Post-Acute Care Specialization Groups and Financial Outcomes

Nursing homes (NHs) have increasingly specialized in post-acute care (PAC). However, it remains unclear as to why some NHs engage in more specialization than the others. Furthermore, the relationship between financial outcomes and PAC specialization has not been examined using more accurate financial indicators. This study developed a NH PAC specialization typology and examined financial outcomes (i.e. total revenue per inpatient day, operating margin) of different specialization groups. We employed NH-level panel data from 2011 through 2017 and focused on over 9,000 urban NHs per year. Multiple data sources were utilized like the Certification and Survey Provider Enhanced Reporting data; Medicare Cost Reports; and Brown University’s LTCfocUS. We employed Latent Profile Analysis to develop distinct NH care specialization groups based on PAC staffing levels. This analysis revealed heterogeneous and clustered patterns of PAC staffing utilization and identified a four-group typology: “low specialization,” “mixed specialization,” “moderate PAC specialization,” and “intensive PAC specialization.” Using fixed-effects modeling, we then examined financial outcomes of the four PAC specialization groups. Although being in a group with higher level of commitment to PAC specialization was associated with higher revenues, it was not necessarily associated with higher operating margins. Further, in stratified analyses, for-profit and not-for-profit NHs showed different patterns in these associations. This suggested that although NHs compete for patients paid at higher reimbursement policies, increased costs may offset higher revenues as a result of specialization. Future studies should track financial outcome trajectories of NHs by care specialization groups in light of various payment innovations.

Frailty and Functional Status improvement after Skilled Nursing Facility based Post-Acute Care

People admitted to a skilled nursing facility (SNF) for post-acute care undergo comprehensive evaluation and rehabilitation, potentially enabling prediction of future functional recovery. We identified the first SNF admission per beneficiary (n=250,159) between 07/01/2014 – 06/30/2016 in a 5% Medicare sample, using the Minimum Data Set (MDS) and the Outcome and Assessment Information Set (OASIS). Episodes were excluded for non-community discharge (n=43,397) or no OASIS admission assessment within 14 days of SNF discharge (n=77,989). A deficit accumulation Frailty Index (FI) was measured on admission MDS assessment and categorized into robust (MDS-FI<0.15), pre-frailty (MDS-FI0.15-0.24), mild frailty (MDS-FI0.25-0.34), and moderate or worse frailty (MDS-FI≥0.35). Outcomes were functional decline obtained from OASIS, readmission, or death after initiation of home care. Functional status was measured by activities of daily living from OASIS assessments. A total of 135,310 SNF episodes were matched to OASIS episodes. Of these, there were 6,472 (4.8%) robust patients, 38,923 (28.8%) pre-frail, 63,727 (47.1%) mildly frail and 26,053 (19.3%) moderately frail or worse. In a logistic regression after adjustment for OASIS admission function, compared to robust status, frailty was associated with hospital readmission or death within 30 days of OASIS admission, (mild frailty OR1.33 [95%CI 1.23-1.45] and moderate or worse OR1.81 [95%CI 1.66-1.97]). Frailty was also associated with functional decline at OASIS discharge, after adjustment for OASIS admission function (mild frailty OR1.50 [95%CI 1.38-1.63] and moderate or worse OR2.30 [95%CI 2.11-2.50]). Among those discharged from SNF with home services, a SNF-based MDS-FI is associated with increased likelihood of poor community outcomes.

Are Stakeholder Prioritized Post-Acute Care Practices Documented and Do They Improve Outcomes?

The receipt and intensity of rehabilitation services, such as occupational and physical therapy, have been associated with lower risk of readmissions. Yet, little is known about the care. This study quantified the frequency of documented post-acute care (PAC) stakeholder-prioritized practices and their associations with hospital readmissions. A PAC stakeholder advisory board (e.g., physicians, rehabilitation providers across settings) prioritized key practices to evaluate. Medicare claims and electronic medical records were used to construct an episode of care for patients age 65 or older. Eligible patients were discharged from one of nine acute hospitals to a PAC setting (i.e., inpatient rehabilitation, skilled nursing, home health) within one large health system between August 2016 and August 2018. Descriptive statistics characterized the cohort and frequency of documented practices. Logistic regression examined associations among the practices and readmissions, by setting. Stakeholders prioritized (a) education, (b) cognition assessment and treatment, and (c) medication management. Among these PAC patients (n=3,227) there was variation in documentation for each practice by setting. Documentation of medication management at any point during the stay ranged from less than 1% to 54% of patient stays among settings. There was a significant relationship between the practices and readmissions. Within inpatient rehabilitation, every additional day patient and caregiver education was documented by occupational therapy was associated with 21% lower odds of readmission (p<0.05). This study highlights the variability in documentation of stakeholder-prioritized practices across PAC and their associations with readmissions. Future work is needed to enhance the systematic delivery and documentation of these practices.